1. Impact of Payment System Reform on Effective Health Services Delivery of China Rural Grass Root Health Facilities – Case Study Design Kun Zhao, Professor China National Health Development Research Center FHS Phase II China Team June 2012

2. Research background Man Phenomenon & Problem ： Clinical health care is deemed too expensive: for health financial protection, individual OOP and government; Lack of sufficient financial support to rural grass root health facilities so that it induces excessive sales of drugs to keep running of facilities ； Problems with quality of care, accountability of health services etc. ； Since health care reform launched in 2009, there is a wide variations of each province and county in responses to the reform and on progress measures taken, the situation is complex.

3. Many provinces, counties declared they had adopted payment reform (about 80%-90%) and move fast; The same payment method may have different scope of conditions covered, reimbursement levels in different areas and change rapidly; The supporting policy for payment reform is unstable; Theory of change is not clear to local PM, because there are ongoing policies which have the complicated relationship with payment reform. Therefore, the impact evaluation question like “ What impact of payment system reform on the quality, cost and availability of health services” is not proper for the context. The case study, especially multiple case study method is chosen to interpret the complexity of China payment reform.

4. Research Objective Under the complicated and continually changing context, we plan to use CAS theory and other relevant theory to interpret the impact of payment reform on effective delivery behaviors of health services provided by china rural grass root health facilities and to summarize the inherent regular pattern, interior and exterior influence relationships of payment system design and health services delivery, aiming to promote health policy-makers and decision makers to consider current institutional arrangements and health services delivery deeply and improve the quality of policy making process. Health care reform Context Delivery system Payment reform consequence

5. Central Research Questions To analyse and understand the adaptation and responses of rural grass root health facilities to the mandate for health payment reforms To make an exploratory analysis of the impacts that these responses to provider payment reform have led to in the rural health system. Research Subject: County focussed - multi-level and multi- organizational Research Period: January 2011 (the promotion phase of payment reform) to September 2016 (the end of the project)

6. Sub-questions 1 (Process questions) How have the payment reforms been designed and implemented? How has county and hospital-specific contexts influenced the nature of reforms implemented? Which actors/stakeholders influenced the implementation of reforms and how?

7. Sub-questions 2 (Consequences ） What are the responses in terms of: (1) intended consequences:- a.Quality of health care (technical quality) b.Rational use of medicines (provider perspectives, medical record review) c.Health care costs (to governments, public, insurance schemes) d.Access of services to the poor e.Patient satisfaction with services (where data available) （ 2 ） Unintended consequences, such as:- a. Up-coding (ie. coding patients to a more expensive case) b. Shifting patients to procedures or case definitions not covered by the payment reform c. Cream skimming – referring (high cost) patients to other hospitals

8. Theoretical Foundations Our approach and analysis will be guided by CAS:- – The FHS Conceptual framework on CAS has informed our study design – We will track change over time and look for emergent behavior – We will stimulate learning through sharing emerging findings We will also explore the relevance of principal agent theory and decision space (Bossert 1998)

9. A starting hypothesis County level governments and health facilities will respond to the new provider payment policies, but the exact nature of their response will reflect contextual factors including:- – The level of management capacity – The local economic situation and in particular the availability of local government revenues versus dependence upon the national government(?) – Type of MIS – Ambition and motivation of county government and local leaders We predict that in those contexts with higher economic and management capacity, stronger MIS and more ambitious leaders, reforms will better designed and implemented, with greater likelihood of success.

10. Research Logical Framework: impact of reform in rural health care system 县的复杂 多变背景 Description of the company’s sub contents Politics Economy History Society Stakeholders Supporting system Environment Regulation system Payment System Reform The Micro Level : Individual The responses of medical staff The Middle Level ： Health facility The responses of health facilities The Macro Level ： County the complicated and continually changing context of counties Intended Consequence Unintended Consequence possible influence and influence route Apperceive and perceive Attitude Subjective norm Perceived behavior control Intended Consequence Control unreasonable growth of cost ； Control irrational use of drug ； Quality assurance/improvement Improve health care accessibility Unintended Consequence Inadequate supply of services Be incapable to control unreasonable cost rising and change unreasonable cost Quality decline Vulnerable people are excluded or do not receive enough benefits Response in perceive level Response in behavior level Apperceiv e /perceive payment system documents Core benefits Maintenance and expansion the maximization of personal interest: Organizational restructuring Financial management system Personnel mechanism Performance investigation mechanism Information technology regulatory system Quality control mechanism National Policy

11. STUDY DESIGN

12. Overall Study Design Case study design – Selection of 3 counties – Within each county select 1 county hospital, 1 township health center and 2 village clinics – Analyze by county Feedback findings to county and township actors at regular intervals and repeat data collection to track change over time

13. Study components 1.Contextual analysis/Initiating conditions – Simple indicators of social, economic, political context (eg. GDP per capita, age profile, education level, employment) – Review of local health system documents 2.Documenting process of reform & understanding political/power dimensions at all levels of the rural health care system – Semi-structured interviews at county, township, and village level – Stakeholder analysis (adapted) – Document review 3.Understanding how new incentives impact individual health professionals – Structured survey in county hospitals, township health centers and village clinics 4.Consequences of Reform – NCMS data base and other hospital level data (intended consequences) – Semi-structured interviews with health facility staff for unintended consequences – Medical record review (both intended and unintended consequences)

14. Sampling 3 typical rural counties from across China purposively selected from (i) Western region (ii) Central region and (iii) Eastern region, to reflect different levels of socio-economic development and bureaucratic capacity

15. Purposive sampling of health facilities within each county Typical NSampleSelection criteria County hospital2-31No. 1 Hospital (typically largest hospital) Township health center 10-201Typical hospital: medium size (beds, staff), not too remote, not in large town Village cliniclots2Select clinic connected to the purposively sampled township health center

16. RESEARCH BY STUDY COMPONENT

17. 1. Contextual Analysis Methods – Simple, readily available indicators captured at the county level eg. GDP per capita, age profile, education level, employment…need to develop a list for this – Document review to address for example: political priorities in health & related sectors, existing health system structure & challenges, extent of decentralization with country County health plan Health facility budgets NDRC annual report Any other relevant documents Frequency – Track indicators on an annual basis, or as frequently as they are measured – Document review: at the start, then follow-up on any new key documents throughout life of project

18. 2. Documenting process of reform in the rural health care system Research questions – How do different actors in the rural health care system understand the payment reform? – What kind of county level provider payment policies have been designed and implemented since reforms started, how have these changed over time, and how has their implementation varied across facilities? – How has the county and facility context affected reforms (eg. economic situation, bureaucratic capacity, political situation, other reforms being implemented)? – Which stakeholders have been influential in shaping reforms and how?

19. 2. Documenting process of reform in the rural health care system Methods – Semi-structured interviews & FGDs:- With county government (NDRC, MOF, Bureau of Health Affairs &NCMS) ~ 5 interviews County hospital ~ 5 interview s with hospital director & Director of new NCMS office, plus 1 FGD with hospital staff Township health center - 3 interviews with health center director & Director of new RCMS office, 1 FGD with health center staff Village clinics – 1 interview in each clinic – Build a county level stakeholder analysis into the semi-structured interviews ie. seek to understand (i) position regarding provider payment reform and (ii) level of influence (perhaps based on respondent ranking of different entities) – Interviews to be taped, transcribed and analyzed using a framework approach – Document review:- County government policy statements NDRC annual report Frequency – Conduct twice during the life of the project - Year 1 and Year 3

20. Subjective norm Behavior Intension Perceived behavioral control Behavior for medical staff Attitude Incentive perceive Incentive signals Incentive apperceive 3. Understanding how provider payment reform affects medical staff – conceptual framework Intended behavior ： Accurate diagnosis outcome Reasonable drug use Reasonable examine … Unintended behavior ： Inaccurate diagnosis outcome Decompose hospitalization, repeated hospitalization Transfer / prevaricate patients Prematurely discharge Excessive drug and examine use High absenteeism and resignation rate – ……

21. 3. Understanding how provider payment reform affects health staff Research questions – How do health staff understand the incentives present in new provider payment mechanisms? – How have provider payment reforms affected the motivation/attitudes of health staff? – How have provider payment reforms affected informal norms? – Do health staff recognize the need to change behavior? – How has provider payment reform affected the behavior/performance of health staff?

22. 3. Understanding how provider payment reform affects health staff Methods – Structured self-administered survey of health staff in all case study health facilities – Sample In each county NSample sizeSampling criteria County hospital 500 -800100-150TBD after nature of reforms is clearer Township health center 35 census Village clinic22census

23. 3. Understanding how provider payment reform affects health staff – Questionnaire design Simple questions about their understanding of payment reforms and incentives Psychometric scales to assess motivation, attitudes etc. Identifying psychometric scales already used in China – Frequency - Conduct twice during project Year 2 and Year 4

24. 4. Consequences of Reform Research questions – How have the reforms impacted on intended variables (eg. costs, quality and accessibility of care among rural populations) and what kind of unintended consequences has the reform had? Methods (i) Use existing data from NCMS, and hospital information system – Frequency – collect on an annual basis – Analyze by each Township hospital – Examine trends over time and link to what is known about the evolution of the payment reform program (ii) Medical record review for appropriateness of care provided (methods require further development) – Identify 3 tracer conditions reflecting high volume services, where treatment is sensitive to financial incentives – Extract sample of medical records – Expert review of medical records to assess appropriateness of care provided – Frequency: twice during project (year 2 and year 4 – to coincide with health worker survey) (iii) Patient satisfaction survey in all study facilities - Develop tools, detailed plan for implementation etc (iv) Interview data on unintended and intended consequences

25. Analyzing and synthesizing across study components (I) Develop detailed descriptions of the nature and process of payment reforms for each county For each county explore how reforms have affected outcomes (intended and unintended) Look for patterns across cases – for example – How has the county context (economic, political, managerial) affected the nature of reforms? – How has the health facility context affected the way in which reforms were implemented? – Make this more specific to theories??

26. Analyzing and synthesizing across study components (II) For all data there is more than one round of data collection – Analyze how policy and policy implementation has changed over time – Why has policy changed – do we see evidence of CAS in the nature of change (eg. path dependence, emergent behavior)? Feedback findings to stakeholders at the county and township level on an annual basis to:- – Validate findings (respondent checking) and help get their interpretation – Potentially stimulate new behaviors

27. SUMMARIZING DATA COLLECTION

28. Sampling Level respondentSemi-structured interviews per county FGDs per county Structured interviews Per county County level50 County hospital5 per hospital1 per hospital100-150 Township health center 3 per health center1 per health center 35 Village clinic1 per clinic (2 in total)02 TOTAL IN ALL 3 COUNTIES 456411-561

29. Methods of data collection by level County Level County Hospital Township HC Village clinic Document review Semi- structured interviews Structured survey Administrativ e data

30. Timing of study components 2012 2013 2014 2015 2016 1. Contextual XXX X XX 2. Process of reform in rural health system XXX 3. Effects on Health staff XXX 4a. Outcomes (based on admin data) X X X X 4b. Outcomes (based on med records & patient satisfaction) XXX 5.AnalysisXX XXXX 6. Report back X X X X

31. Next steps Finalizing drafts: – Interview guide for county government – Interview guides for County hospital and township health center and village clinic management – Data extraction guide for document review (national, county level) – Table for extracting data for consequences (review feasibility based on data sets) – Spreadsheet for contextual data/indicators – Field works in this September Developing instruments – Health worker survey (Year 2) – Medical record review form (Year 2) – Patient satisfaction questionnaire (Year 2)

32. Thanks !!